HomeMy WebLinkAboutSeptic Pumping Slip - 54 LONG PASTURE ROAD 3/14/2016 Commonwealth of chu tt �
City/Town y/Town Of North Andover � � ���}
u i
,• w Pumping �tf fit�fi
System I � rr,/`Uf4fIi }y
a
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:When
p " ... _
filling o forms 1. System Location: \
on the computer, ., h ❑y � ,
use only the tab ���. ._ ��
key to move your Address
cursor-do not North Andover Ma 01845
use the return — -
key.
City/Town State Zip Code
2. System Owner:
Name
ie�wn
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
� w
�ll-
1. Date of Pumping — ! � 2. Quantity Pumped: /` X),
Date Gallons
3. Type of system: ❑ Cesspool(s) ] Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): 11-
Effluent Tee Filter present? ❑ Yes [❑I No If yes, was it cleaned? ❑ Yes El No
5. Condition of System: //
- ❑❑ . .......
6. ystem Pumped By:
- ❑ - -
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
St wart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 -
gn "ure of Hau der Date
----------- ❑- ---
l._.. � ._.._�._.._�_._.�.�, ❑ ��-�
-_—-----------------------—-------- ............_._..-- —
Signature of RebeiVing Facility Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
❑ W City/Town of NORTH ANDOVER MASSA&IM",
a° System Pumping Record;i ?Bet
a Form
ro wlq OF NORIM AIwIDOV R
DEP has provided this form for use by local Boards of Health. t d must
be submitted to the local Board of Health or other approving authority.
A. Facility Information
Important;
filling When t
fcamputert use 1. S Stem LpcatlOn:
Y
only the tab key Address �mm
to move your ❑
cursor-do not �..f
use the return City/Town State Zip Code
key 2. System Owner:
� ,..
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) d'8'eptic Tank ❑ Tight Tank
❑ Other(describe): - -
4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
K� �
6. S st
em Pum d B
." Vehicle License Number
Company 1
7. Location w
e contents were disposed: IN
l C/( �— - -
g"'"ure of Hauler Date
http://www.mass.gov/dep/Water/approvals/t5forms.htm#inspect
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
'Q9,mmonwealth of Massachusetts
. Fora
p ,
DEP has provided this form for use by local Boards of Health". The System Pumping p yR cord mu,
be submitted to the local Board of Health or other approving utho
A. Facility Information
Important:
When filling out 1, System Location:
forms Che
computer,use _
a
only the tab key Address -' '� - --•- ------_ __..._..
to move your '/1
cursor-do not lt /7own - —�` ----
use the return C y State _ Zip Code—' --
key.
2, System Owner:
Name — ________ _ -___—..• __-.�_,_,__..____ __.____ ___.---._---..._- ,.
Address(if different from location)
State -
Zip Cade
Telephone e Number
,,. .,.. . PUmping Record —
Date.of Pumping Date -- quantity Pumped;
`� � Gallons
3 yps of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Qtner(describe);
p ❑ Yes No If yes, was it cleaned? — " Yes
a
4. Effluent Tee Filter resent? [ ❑ No
5. Condition of System:
61 Sy em Pumped By:
ame _�_
d Vehicle License Number --
Company
7. Location where contents were disposed f
Si atfi ure o(Hau /% _-_- —_ __ _at -
� Date ?�
http://www,mass,-goV/dep/water/ provals/t5forms,htm#inspect
15form4.doc-06/03 System Pumping Record-Page 1 of i
�rnM onwealth of Massachusetts
` pity 6inir MASSACHUSETTS
Sy' t ' ping rd
h
�• Fora 4
DEP has provided this form for use by local Boards of Heal h. Thl P
system pumpin ecord mu;
be submitted to the local Board of Health or other approvin authorty .r ,q t Il.arx�fw
A. Facility Information
Important:
When filling out 1. System Location:
forms on the .
computer, use
only the tab key Address _ ...-
to move your
cursor-do not --- � c e ✓� ! ( �
use the return
key. 2. Sy Cltyftown
Zip Cade
stem Owner: t
Name
Address(if dl )
Nerent from laaation) ._--._T____._._,-•------�,..----..._.--_---_—--._._--
Clty/Tawn --
State — Zip Code -. .
Telephone Number ---.-- -_.
B. Pumping Record
•1. Date.of Pum in g g zv -- 2. Quantity Pumped:
Gallons -----._--
Type of system: ® Cesspool(s) ❑'Septic Tank ❑ Tight Tank
mm, ❑ Other(describe):
4. Effluent Tee Filter present? El"'Yes ❑ No If yes, was it cleaned? ❑'Yes ❑ No
r
5. Condition of System: 4
6, Sy em Pumped 6y:
ame
r Vehicle License Number
Company
7. , Location where contents were disposed: J
- W
Si
*Hau
Date
http://www.mass,gov/dep/water/ provals/t5forms,htm#inspect
t5form4.doc-06/03
System Pumping Record Page 1 of i